- Email: [email protected]
TREATMENT OF BRONCHIAL CARCINOMA
157 TREATMENT OF BRONCHIAL CARCINOMA Sm,-As chairman of the M.R.C. working-party on the evaluation of different methods of therapy in carcinoma of the bronchus I should like to comment on some of the correspondence which followed its first report.1 Mr. Kent Harrison2 suggests that the report might be taken to indicate " that surgery has no place in the treatment of oatcell carcinoma of the bronchus in general " and that we might wish to qualify our report. Our conclusion in fact was " that radical radiotherapy is preferable to surgery for the treatment of small-celled or oat-celled carcinoma ". However, I fully accept Mr. Abbey Smith’s point3 that, since the patients included in the trial were diagnosed on a positive bronchial 1biopsy, the findings may not necessarily apply to patients with oat-celled tumours. Mr. Abbey Smith’s view that ; peripheral those patients with peripheral tumours, in whom a cytological diagnosis of oat-celled carcinoma has been made, are better treated by surgery than by radical radiotherapy could be put to a comparative trial if a sufficient number of centres making diagnoses on sputum cytology would be prepared to join a
a large volume of clinical work, give this, but they also bring a fresh wind to the training sail. They must be accorded their full due and made the central point of training, which must become more fully a training experience, and not merely the routine drudgery and night-work which most senior registrars seek to escape by becoming consultants.
take
University Department of Surgery, Royal Melbourne Hospital, Parkville N.2, Victoria, Australia.
E. A. ALLCOCK.
MOTES AND BEAMS SiR,-Pronouncements and expressions of opinion in a leading article in The Lancet are always accepted with great respect and regarded as authoritative. It is therefore with considerable concern that we read on Jan. 7 (p. 31) a commentary on the Royal Colleges which is simply untrue. In particular, fellows of our College have drawn our attention to the
following
sentence:
" Unsure of their relevance or function in the ’60s, the older colleges continue to dominate postgraduate qualifications yet shirk the responsibility of postgraduate education-with the notable exception of the Royal College of Surgeons of England, whose present efforts are described by its President in a letter on a later page."
We should like to point out that the Royal College of Surgeons of Edinburgh, the College of which we have most knowledge, has for many years been most active in the sphere of postgraduate medical education, as has our sister college in London. As you are evidently unaware of our activities, we should like to inform you that in 1960, when Sir John Bruce was president of the College, a committee was set up to review the training of surgeons, the report of the committee being published in 1963. On our College premises the Pfizer Foundation building was built and opened in 1965, and adjoining it, also on College property, the Lister postgraduate building for research and teaching in the basic sciences related to surgery is nearing completion, and will be opened later this year by Lord Florey. These fine buildings will greatly improve the facilities for our postgraduate students. In Edinburgh postgraduate education is in the hands of the; Edinburgh Postgraduate Board for Medicine, on which our College is represented equally with the Royal College of Physicians of Edinburgh and Edinburgh University, and isi therefore an integral part of the Board; this can hardly be described as shirking the responsibility for postgraduate: education ". During the ’60s about 1000 students attended the: Board’s courses each year. Among the College’s recent activities we should mention the inauguration of a Wade professorship, the Wade professor delivering lectures and giving demonstrations in the College museum for a period of several weeks.:. The first Wade professor was Prof. William Boyd. A numberr of Wade demonstratorships have also been introduced, demonstrations being given to postgraduates on the unique collection n of pathological material in the College museum. This project :t is proving a great success. Our College has worked in the closest association with our Lr sister colleges in the approval and institution of certain principles in the training of surgeons, to which Professor Atkins refers so clearly in his letter (Jan. 7, p. 44). The working party "
-
-
-
-
of the Scottish Post-Graduate Medical Association on postgraduate medical education in Scotland will very shortly be reporting its findings; these will show that in Scotland postgraduate education is at least as far ahead as south of the Border. Knowing as we do the great activity displayed by our own College and by our sister colleges, working in recent years in close cooperation with our universities in postgraduate affairs, we can only deplore the ill-informed and inaccurate information about the Royal Colleges displayed in the columns of your
leader. G. I. SCOTT President
Royal College of Surgeons,
Edinburgh
8.
JAMES A. Ross Secretary.
cooperative study. The comparision between the two series which is of the greatest practical use is that made in the report-namely, a comparison of policies of treatment as applied to all patients in each series; this is also a valid comparison statistically, because the series were established by random allocation and there was no differential exclusion of patients. This comparison marginally favoured the radiotherapy series. However, even if the less useful comparison preferred by Mr. Belcher 4 is made, the mean survival of the 58 patients who had a thoracotomy (194 days) is less than that of the 70 patients who had radiotherapy, whether radical or palliative (263 days). This difference is also unlikely to be due to chance (P=0-05), but the contribution made to it by clinical differences between these two selected groups of patients cannot be assessed. As we observed, the results of treatment in this form of bronchial carcinoma are very poor, and further research is needed to improve them. Major improvement may well have to await advances in the therapy of cancer in general. Nevertheless, the working-party is currently concerned with studies of several combinations of widely used methods of treatment -surgery, radiotherapy, and chemotherapy-in carcinoma of the bronchus. It appears to us important to obtain reliable evidence about the comparative value of available methods even though the best application of them is unlikely to reduce the appalling and steadily increasing number of deaths from this disease sufficiently to affect the epidemiological trend. Our most important conclusion was that " there is an urgent need to apply the knowledge already available, in particular that of the role of cigarette smoking, to the prevention of the disease ". The facts should be publicised: the incidence of a disease which has assumed epidemic proportions, which has a high mortality, and for which no current method of treatment can be regarded as satisfactory, would be reduced to a small fraction of its present level if men and women as responsible individuals chose to give up, or never to take up, cigarette-
smoking. Institute of Diseases of the Chest, Brompton, London S.W.3.
J. G. SCADDING.
CARCINOMA OF THE NASOPHARYNX SiR,-Your annotation5 rightly stresses the importance of early diagnosis and its difficulty on clinical grounds alone. Plain radiographs of the nasopharynx may be of some help, and are particularly useful for showing bone destruction if this is present, but again the detection of small early lesions is not easy. Air in the nasopharynx under these circumstances acts 1. See Lancet, 1966, ii, 979. 2. Harrison, K. ibid. p. 1254. 3. Abbey Smith, R. ibid. p. 1134. 4. Belcher, J. R. ibid. p. 1190. 5. ibid. p. 1455.
a large volume of clinical work, give this, but they also bring a fresh wind to the training sail. They must be accorded their full due and made the central point of training, which must become more fully a training experience, and not merely the routine drudgery and night-work which most senior registrars seek to escape by becoming consultants.
take
University Department of Surgery, Royal Melbourne Hospital, Parkville N.2, Victoria, Australia.
E. A. ALLCOCK.
MOTES AND BEAMS SiR,-Pronouncements and expressions of opinion in a leading article in The Lancet are always accepted with great respect and regarded as authoritative. It is therefore with considerable concern that we read on Jan. 7 (p. 31) a commentary on the Royal Colleges which is simply untrue. In particular, fellows of our College have drawn our attention to the
following
sentence:
" Unsure of their relevance or function in the ’60s, the older colleges continue to dominate postgraduate qualifications yet shirk the responsibility of postgraduate education-with the notable exception of the Royal College of Surgeons of England, whose present efforts are described by its President in a letter on a later page."
We should like to point out that the Royal College of Surgeons of Edinburgh, the College of which we have most knowledge, has for many years been most active in the sphere of postgraduate medical education, as has our sister college in London. As you are evidently unaware of our activities, we should like to inform you that in 1960, when Sir John Bruce was president of the College, a committee was set up to review the training of surgeons, the report of the committee being published in 1963. On our College premises the Pfizer Foundation building was built and opened in 1965, and adjoining it, also on College property, the Lister postgraduate building for research and teaching in the basic sciences related to surgery is nearing completion, and will be opened later this year by Lord Florey. These fine buildings will greatly improve the facilities for our postgraduate students. In Edinburgh postgraduate education is in the hands of the; Edinburgh Postgraduate Board for Medicine, on which our College is represented equally with the Royal College of Physicians of Edinburgh and Edinburgh University, and isi therefore an integral part of the Board; this can hardly be described as shirking the responsibility for postgraduate: education ". During the ’60s about 1000 students attended the: Board’s courses each year. Among the College’s recent activities we should mention the inauguration of a Wade professorship, the Wade professor delivering lectures and giving demonstrations in the College museum for a period of several weeks.:. The first Wade professor was Prof. William Boyd. A numberr of Wade demonstratorships have also been introduced, demonstrations being given to postgraduates on the unique collection n of pathological material in the College museum. This project :t is proving a great success. Our College has worked in the closest association with our Lr sister colleges in the approval and institution of certain principles in the training of surgeons, to which Professor Atkins refers so clearly in his letter (Jan. 7, p. 44). The working party "
-
-
-
-
of the Scottish Post-Graduate Medical Association on postgraduate medical education in Scotland will very shortly be reporting its findings; these will show that in Scotland postgraduate education is at least as far ahead as south of the Border. Knowing as we do the great activity displayed by our own College and by our sister colleges, working in recent years in close cooperation with our universities in postgraduate affairs, we can only deplore the ill-informed and inaccurate information about the Royal Colleges displayed in the columns of your
leader. G. I. SCOTT President
Royal College of Surgeons,
Edinburgh
8.
JAMES A. Ross Secretary.
cooperative study. The comparision between the two series which is of the greatest practical use is that made in the report-namely, a comparison of policies of treatment as applied to all patients in each series; this is also a valid comparison statistically, because the series were established by random allocation and there was no differential exclusion of patients. This comparison marginally favoured the radiotherapy series. However, even if the less useful comparison preferred by Mr. Belcher 4 is made, the mean survival of the 58 patients who had a thoracotomy (194 days) is less than that of the 70 patients who had radiotherapy, whether radical or palliative (263 days). This difference is also unlikely to be due to chance (P=0-05), but the contribution made to it by clinical differences between these two selected groups of patients cannot be assessed. As we observed, the results of treatment in this form of bronchial carcinoma are very poor, and further research is needed to improve them. Major improvement may well have to await advances in the therapy of cancer in general. Nevertheless, the working-party is currently concerned with studies of several combinations of widely used methods of treatment -surgery, radiotherapy, and chemotherapy-in carcinoma of the bronchus. It appears to us important to obtain reliable evidence about the comparative value of available methods even though the best application of them is unlikely to reduce the appalling and steadily increasing number of deaths from this disease sufficiently to affect the epidemiological trend. Our most important conclusion was that " there is an urgent need to apply the knowledge already available, in particular that of the role of cigarette smoking, to the prevention of the disease ". The facts should be publicised: the incidence of a disease which has assumed epidemic proportions, which has a high mortality, and for which no current method of treatment can be regarded as satisfactory, would be reduced to a small fraction of its present level if men and women as responsible individuals chose to give up, or never to take up, cigarette-
smoking. Institute of Diseases of the Chest, Brompton, London S.W.3.
J. G. SCADDING.
CARCINOMA OF THE NASOPHARYNX SiR,-Your annotation5 rightly stresses the importance of early diagnosis and its difficulty on clinical grounds alone. Plain radiographs of the nasopharynx may be of some help, and are particularly useful for showing bone destruction if this is present, but again the detection of small early lesions is not easy. Air in the nasopharynx under these circumstances acts 1. See Lancet, 1966, ii, 979. 2. Harrison, K. ibid. p. 1254. 3. Abbey Smith, R. ibid. p. 1134. 4. Belcher, J. R. ibid. p. 1190. 5. ibid. p. 1455.